OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2025 Drug List (Pharmacy Benefit) — Formulary and Coverage Criteria

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - Oklahoma policy alerts

Know when Blue Cross Blue Shield - Oklahoma releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

A formulary/drug list that identifies covered prescription drugs, tiers, special requirements, and coverage rules for Blue Cross and Blue Shield of Oklahoma pharmacy benefits; intended for members, prescribers, and pharmacists.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy Benefit) — Formulary and Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual formulary update (no material coverage changes)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization where a drug line is noted 'PA' before dispensing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6member payment tiers described

30/90supply limits typical

MyPrime.comexternal drug list site

multipleagents with QL specified

severalagents requiring PA/SP

levels 0-11Palforzia formulations listed

Coverage Criteria and Formulary Listings

General pharmacy coverage criteria

Covered when ALL of the following apply:

Formulary coverage basics: Drug is listed on the BCBSOK 2025 Drug List (drugs not shown on the list are not covered).

From formulary introduction

Regulatory requirement: Drug has FDA approval for the requested indication; non–FDA‑approved drugs are not covered unless plan materials specify otherwise.

Non‑FDA‑approved drugs excluded per coverage considerations

Benefit and site of care: Coverage is provided under the pharmacy benefit unless the drug is administered by a health care professional and the plan directs medical‑benefit coverage; verify benefit placement via plan materials or the number on the ID card.

Site‑of‑care distinction; see plan materials

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2025 Drug List (Pharmacy Benefit) — Formulary and Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual formulary update (no material coverage changes)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization where a drug line is noted 'PA' before dispensing.

SourceLink

On This Page

Authorization and program requirements: If the product line shows 'PA', 'ST', or other Special Requirements (e.g., QL, SP, AC), the corresponding prior authorization, step‑therapy or quantity/dispensing/specialty routing requirements must be met before coverage is allowed.

PA/ST/QL/SP flags noted next to products

Quantity/dispensing limits: When a QL or DL is listed for the product, dispensing is limited to the stated quantity/timeframe; quantities above the limit may be denied or result in member liability.e.g., QL 30 tablets/30 days, QL 100 mL/30 days

Dispensing limits enforced per coverage considerations

Formulary coverage with tier and administrative controls

Covered according to the product line when ALL of the following apply:

Tier-based coverage: Coverage and member cost share follow the Drug Tier assigned to the product (e.g., P, NP, P+, NP+); follow per‑product tier placement.

Tier shown on each product line

Administrative controls: Products labeled with 'PA', 'QL', 'SP', 'ST' or 'AC' are subject to those administrative controls; the specific product line entry defines which controls apply.

See individual product Requirements/Limits column

Quantity limits examples: When QL is specified, dispensing is limited to the stated quantity/timeframe (examples include azithromycin QL 60 tablets/180 days; clarithromycin ER QL 28 tablets/30 days).Example QLs shown on product lines

Exact QL per product line

Vaccine and biological product coverage

Vaccine and biological products listed are covered when ALL of the following are met:

Listed vaccine on formulary: Requested vaccine or biological is the same product/strength as a line on the Drug List (examples: HIBERIX, JYNNEOS, PFIZER‑BIONTECH COVID‑19, SHINGRIX, etc.).

Vaccine lines include Drug Tier and Requirements/Limits

Administrative designation for vaccines: If the vaccine line specifies 'AC' (ACA/administrative coverage) or other Special Requirements, those administrative conditions must be met for coverage or reduced member cost‑sharing as applicable.

AC indicated in Special Requirements column

Site of care/benefit verification: For provider‑administered vaccines, verify whether coverage is under the pharmacy or medical benefit per plan materials; follow the ID‑card contact for questions.

See plan materials or MyPrime.com for placement

Antineoplastics and specialty drug coverage controls

Antineoplastics and specialty agents are covered subject to the following conditions:

Per‑product administrative controls: Coverage for antineoplastic and specialty oral agents is governed by the Requirements/Limits shown on each product line (commonly PA, QL, and SP).

Examples: abiraterone QL 120 tablets/30 days; alectinib PA, QL, SP

Prior authorization for specialty oncology agents: When 'PA' is indicated for an antineoplastic, a prior authorization must be obtained before coverage is provided.

PA flags appear in Requirements/Limits

Quantity and specialty handling: Quantity limits (QL) and Specialty Pharmacy (SP) routing apply as listed; providers must follow specialty dispensing and quantity documentation requirements when present.e.g., QL 120 tablets/30 days; SP indicated

Per‑product QL/SP entries govern dispensing

Palforzia (peanut oral immunotherapy) coverage

Palforzia (peanut oral immunotherapy) products are covered when ALL of the following are met:

Product on formulary: Requested Palforzia pack/level (initial dose, Levels 0–11, maintenance or titration packets) is listed on the Drug List.

Multiple Palforzia levels and packs are enumerated on the list

Specialty dispensing: Palforzia entries are marked 'SP' (Specialty Pharmacy); specialty pharmacy routing/handling must be used as indicated on the product line.

Requirements/Limits = SP on Palforzia lines

Tier and coverage: Palforzia products are shown with Drug Tier = NP; coverage and member cost‑share follow the NP tier subject to the SP routing requirement.

Drug Tier = NP indicated on Palforzia lines

Product-specific coverage entries

Each product line governs coverage when ALL of the following apply:

Product‑specific requirement: Coverage for the requested product follows the Drug Tier and the Requirements/Limits shown on that product line (examples include AC, PA, QL, SP).

Per‑product entries describe exact requirement text

Contraceptives and QL/AC: Contraceptive products marked 'AC' or 'QL' require meeting the listed administrative/quantity requirements for coverage (example QL 28 tablets/21 days for many oral contraceptives).QL 28 tablets/21 days

See contraceptive product lines

Antidiabetic agents and injectables: Antidiabetic products may have PA and QL as listed (examples: FARXIGA QL 30 tablets/30 days; MOUNJARO PA + QL), and insulin QL values (commonly 100 mL/30 days) apply per product line.e.g., QL 30 tablets/30 days; QL 100 mL/30 days

See antidiabetic and insulin product lines

Formulary coverage with per-drug restrictions

Formulary coverage with per‑drug restrictions — apply ALL of the following:

Per‑drug flags govern coverage: For any prescription, follow the Drug Tier and Requirements/Limits specified on the drug's formulary line. PA, QL, SP and ST flags on that line control coverage adjudication.

Per‑drug restrictions listed on each product line

Denial risk if requirements unmet: Claims may be denied or adjudicated non‑covered if PA is required and not obtained, if QL is exceeded, or if SP routing is required but not used.

See coverage considerations and denial risk notes

Formulary inclusion with annotated restrictions

Coverage of listed products is subject to ALL of the following:

Inclusion on the Drug List: Product must appear on the Drug List with the requested strength/pack to be covered under the pharmacy benefit at the listed tier.

Per formulary entries

Administrative annotations: If the listing includes 'PA' and/or 'QL', the prescriber must obtain prior authorization and/or adhere to the quantity limits shown for coverage to be approved.e.g., QL 100 mL/30 days; PA indicated

Follow per‑product annotations

Formulary product-level coverage rules

Product‑level coverage rules — coverage requires ALL of the following to be met:

Product match and tier: Requested drug (product/strength/pack) must match a line on the formulary; coverage and cost‑sharing follow the Drug Tier shown.

Each drug line indicates Drug Tier

Adherence to Requirements/Limits: Prescriber and pharmacy must satisfy any Requirements/Limits shown (PA, QL, SP); failure to obtain required authorizations or to comply with QL/SP routing may result in denial or member financial responsibility.

Per product Requirements/Limits columns

Formulary coverage indicators

Formulary coverage indicators — apply ALL of the following when determining coverage:

Interpretation of flags: Use the Special Requirements column on each product line to determine whether PA, QL, ST, SP or AC apply; these indicators control coverage and prior authorization needs.

ST denotes step therapy; PA denotes prior authorization; QL denotes quantity limit; SP denotes specialty pharmacy; AC denotes ACA preventive handling

Follow plan materials for specifics: When a flag is present, follow plan‑specific PA/step procedures and documentation requirements (see member ID card/provider portal or MyPrime.com for details).

Refer to plan materials for PA forms/timelines

Formulary coverage with administrative controls

Coverage subject to administrative controls — the drug is covered when ALL of the following are satisfied:

Drug listed and flags complied: The drug appears on the Drug List and any listed administrative controls (PA, QL, SP) are satisfied per the product line before adjudication for coverage.

Per product Requirements/Limits

Exceptions and appeals: If a requested product is subject to PA or other controls and the prescriber requests an exception, the member or prescriber may call the number on the ID card; exception decisions follow standard timeframes (15 days or expedited 72 hours where applicable).15 days / 72 hours

Exception request process per coverage considerations

Drugs that are not listed on the 2025 Drug List are not covered under the pharmacy benefit. The formulary further states that non–FDA‑approved drugs, repackaged, and compounded medications may not be covered; members and prescribers should confirm coverage via the member ID card phone number or online at MyPrime.com or the BCBSOK provider portal. Prior authorization (noted as PA in the Special Requirements column) may be required for certain products and must be obtained for coverage when indicated.

Within the excerpted formulary sections there are no product-level clinical exclusion statements (e.g., explicit lists of diagnoses or clinical scenarios that render a drug not covered). The document instead provides per‑product Drug Tier codes and administrative flags (such as PA, QL, SP, or AC) that govern coverage and utilization management.

Some listed entries show Drug Tier codes such as NP or are left blank; these listings are tier annotations used to determine member cost‑share and do not themselves define clinical exclusion criteria. When a product is shown as NP or blank, coverage remains subject to the listed administrative controls (e.g., PA, QL) and the plan’s general terms.

The provided chunks do not state any explicit formulary exclusions (statements such as 'not covered' for specific drugs). Coverage determinations are represented by product-level tier assignments and Requirements/Limits tags rather than by explicit per‑drug exclusion language in this excerpt.

Items listed without a specific Requirements/Limits entry still appear on the drug list and may be subject to the plan’s general terms, tier-based cost sharing, and other benefit provisions. Absence of a PA/QL/SP tag in the excerpt does not guarantee unrestricted coverage; providers should verify benefit details for a member.

Certain products display different Drug Tier codes depending on the strength or formulation (for example, strengths or dosage forms of the same drug may be assigned to different tiers). Providers should confirm the exact listed strength/formulation on the drug list because tier and member cost‑share can vary by strength/formulation.

Some drugs are present on the formulary but only partially annotated with utilization management flags; the excerpt therefore provides formulary listing and tier placement but does not include detailed medical‑necessity criteria for many entries. Where PA, QL or ST are shown next to a product, those administrative controls apply even if the full clinical documentation requirements are not printed in this excerpt.

Across the sections cited there are no explicit product-level exclusions

The excerpt contains no explicit clinical exclusion statements for the products shown. Instead, coverage is governed by the product’s tier and any associated administrative designations (e.g., PA, QL, SP). Providers may request exceptions per the plan’s process when coverage questions arise.

In the excerpted listing there are no explicit 'Not Medically Necessary' declarations for products or classes. The document instead identifies utilization controls (e.g., PA, QL, AC) and directs prescribers to submit prior authorization requests with supporting documentation where required.

Review of the provided segments shows no explicit 'Not Medically Necessary' statements. The formulary communicates coverage via tiers and requirement flags; determinations about medical necessity would follow the payer’s prior authorization and clinical review processes when applicable.

The document excerpts do not present explicit statements labeling drugs as 'not medically necessary.' Instead, therapeutic coverage is expressed through tier placement and utilization management tags; where clinical denial would be appropriate, that outcome would be reached through the plan’s review of PA submissions against clinical criteria (not shown here).

No individual drug lines in these chunks include explicit 'not medically necessary' language. When utilization controls such as PA or QL are present, the plan requires documentation or authorization for coverage rather than stating a product is categorically not medically necessary in this excerpt.

There are no explicit 'Not Medically Necessary' declarations in the examined sections. The formulary relies on administrative flags (for example, ST for step therapy, PA for prior authorization) to manage appropriate use; adverse medical‑necessity determinations would be made through the payer’s clinical review processes.

Within these excerpted chunks the listing does not include explicit statements that any listed products are 'not medically necessary.' Coverage restrictions are communicated via tier codes and requirement/limit tags; clinical denial rationale is not presented in this portion of the drug list.

Coding and Quantity Limit Examples

Drug list (no billing codes)NDC

NDCs not listed

No NDC codes provided in this excerpt; only product names and strengths are present.

Vaccine product list (no billing codes provided in this segment)mixed

No codes listed

Antineoplastic and specialty oral agents (no CPT/HCPCS/NDC codes provided here)mixed

No codes listed

No procedure/diagnosis codes in these chunksmixed

No codes listed

Formulary items (no billing codes)mixed

N/A	This section is a drug formulary list; no procedure/CPT/HCPCS/ICD codes provided in these chunks.

Formulary product potency notationmixed

1:2000

epinephrine solution auto-injector 0.15 mg/0.3ml (Epipen-jr 2-pak) — potency notation appears as (1.2000) in document

Drug list (no billing codes provided)NDC | mixed

No codes listed

Formulary drug entries (no procedural codes in this segment)NDC | mixed

No codes listed

Drug product listings (no CPT/HCPCS/ICD-10 codes in these chunks)NDC | mixed

NDCs not listed

Document lists drug products and strengths but does not provide NDC codes in these chunks.

NDC/Codes not presentmixed

No codes listed

Example Quantity Limits

Azithromycin (oral formulations)QL 60 tablets per 180 days

Clarithromycin ER 500 mgQL 28 tablets per 30 days

NUZYRA (omadacycline) 150 mgQL 30 tablets per 180 days

Itraconazole (capsules)QL 120 capsules per 30 days

Antiretroviral single‑tablet regimens (e.g., BIKTARVY, GENVOYA)QL 30 tablets per 30 days

Quantity limits examples

Oral oncology examples (selected)QL 120 tablets per 30 days (example for some agents)

Higher oncology QL exampleQL 240 capsules per 30 days (agent‑specific)

Lower oncology QL exampleQL 30 tablets per 30 days

Common quantity limits

Common short‑course limits (contraceptives)QL 28 tablets per 21 days (combined oral contraceptives)

NuvaRingQL 1 ring per 21 days

Oral antidiabetics (sample)QL 30 tablets per 30 days (e.g., FARXIGA, JANUVIA, JARDIANCE)

Insulin common QLQL 100 mL per 30 days (many insulin products)

Common Quantity Limits (insulins)

Typical insulin dispensing limitQL 100 mL per 30 days (applies to most listed insulins)

Multiple insulin examplesNOVOLIN N, NOVOLIN 70/30, NOVOLOG MIX 70/30, INSULIN GLARGINE‑YFGN, SEMGLEE, TOUJEO, TRESIBA — QL 100 mL

Pen/cartridge configurationsVarious pen and cartridge pack sizes subject to the 100 mL/30 days QL as listed

Quantity limits for listed oral solutions and kits

Enalapril maleate oral solution (Epaned)PA, QL 1200 mL per 30 days

QBRELIS (lisinopril oral solution)PA, QL 2400 mL per 30 days

FUROSCIX furosemide subcutaneous cartridge kitPA, QL 8 kits per 180 days

Quantity limits examples (specialty injectables)

SKYRIZI (risankizumab) cartridgePA, QL 1 cartridge per 56 days

ZYMFENTRA (infliximab‑dyyb) kitsPA, QL 2 kits per 28 days

VOWST (fecal microbiota spores, live)PA, QL 12 capsules per 12 months

Aripiprazole oral solutionQL 900 mL per 30 days

Quantity Limits examples (section)

Standard oral tablet/capsule QLs (examples)30 tablets per 30 days; 60 tablets per 30 days — commonly applied to many oral meds

Longer interval examples8 tablets per 180 days; 1 pack per 180 days

Large‑volume oral liquid examples540 mL per 30 days; 480 mL per 30 days

Pen/pack QLs for weight‑management/GIP‑GLP agentse.g., Wegovy 8 pens per 180 days or 4 pens per 28 days; Zepbound 4 pens per 180/28 days as listed

Example quantity limits

Examples of shorter/alternate QLs30 capsules per 30 days; 28 capsules per 180 days; 2 syringes per 28 days (example for some injectables)

Pack‑based limits2 kits per 28 days (example for some biologic kits)

Syringe limits2 syringes per 28 days (example for certain fertility/biologic preparations)

Prior Authorization, Step Therapy, and Documentation

Prior Authorization
Obtain prior authorization when 'PA' is listed
Prior authorization is required for medications when the drug listing shows 'PA' in the Special Requirements column; clinicians must submit a prior authorization request and receive approval before the plan will cover the medication. Examples of PA notations are shown across the formulary and described in the Coverage considerations section.

Prior Authorization
PA required for select inhaled/complex aminoglycosides
Certain listed agents explicitly require prior authorization (PA) — providers must submit PA for those products before dispensing; examples include KITABIS PAK and tobramycin nebulized products which are noted with PA and SP flags.
KITABIS PAK tobramycin nebu soln — Requirements/Limits = PA, QL (56 containers/56 days), SP
TOBI PODHALER tobramycin inhal cap — Requirements/Limits = QL (224 capsules/56 days), SP PA

Prior Authorization
PA required for specialty antineoplastics and high-cost agents
Many specialty and antineoplastic agents are designated with PA and often SP; prescribers must request prior authorization for these specialty drugs before coverage is provided.
Examples: ALECENSA (alectinib) — Requirements/Limits = PA, QL, SP; ALUNBRIG (brigatinib) — Requirements/Limits = PA, QL, SP
Numerous other oncology/specialty entries show PA and SP in Requirements/Limits

Prior Authorization
Request PA for listed products (antivirals/antifungals)
Selected drugs across the formulary include PA annotations (or AC) next to the product line; providers must obtain authorization where indicated (e.g., certain antivirals and antifungals).
NOXAFIL (posaconazole) formulations — Requirements/Limits = PA
EPCLUSA and HARVONI (hepatitis C agents) — Requirements/Limits include PA, SP

Prior Authorization
Request PA and specialty routing where indicated
When a drug's Requirements/Limits field shows 'PA' or 'SP', providers must request prior authorization and follow specialty pharmacy routing where applicable prior to dispensing.

Prior Authorization
Submit PA and comply with stated quantity limits
Some products are listed with both prior authorization (PA) and specific quantity limits (QL); providers must obtain PA and ensure prescriptions adhere to the stated QL (claims may be denied if limits are exceeded).
Enalapril maleate oral solution (Epaned) — Requirements/Limits = PA, QL (1200 mls/30 days)
QBRELIS lisinopril oral solution — Requirements/Limits = PA, QL (2400 mls/30 days)
FUROSCIX furosemide subcutaneous cartridge kit — Requirements/Limits = PA, QL (8 kits/180 days)

Prior Authorization
PA required for many specialty/high-cost medications
Multiple specialty and higher-cost drugs require prior authorization — providers must submit PA requests for these products (examples include REPATHA, NEXLETOL/NEXLIZET, VASCEPA, ENTRESTO, and biologics such as NUCALA/FASENRA).
REPATHA evolocumab — Requirements/Limits = PA, QL (6 syringes/28 days)
NUCALA mepolizumab — Requirements/Limits = PA, QL (3 mL/28 days), SP

Prior Authorization
Obtain PA for listed biologic/specialty products
Specific high-cost biologics and specialty agents are listed with PA (and often SP); prescribers must obtain prior authorization for these products before coverage (examples: SKYRIZI, TREMFYA, ZYMFENTRA).
SKYRIZI risankizumab — Requirements/Limits = PA, QL (1 cartridge/56 days), SP
TREMFYA guselkumab — Requirements/Limits = PA, QL (1 syringe/28 days), SP
ZYMFENTRA infliximab‑dyyb — Requirements/Limits = PA, QL (2 kits/28 days), SP

Prior Authorization
PA required for specified formulary products
Certain listed products explicitly include 'PA' in their Requirements/Limits; providers must obtain prior authorization for these items prior to adjudication (examples in the formulary segment include SKYRIZI, TREMFYA, VOWST).
VOWST fecal microbiota spores, live — Requirements/Limits = PA, QL (12 capsules/12 months), SP

Prior Authorization
PA required for PA‑designated products
Products explicitly labeled 'PA' in the drug list require prior authorization before coverage; prescribers must submit PA requests as directed by the plan.
Examples: Hetlioz oral suspension (tasimelteon) — Requirements/Limits = PA, QL; Wegovy, Zepbound, Saxenda — Requirements/Limits = PA, QL

Prior Authorization
Follow payer PA procedures and submit required requests
The formulary notes that many products require prior authorization; providers must follow the payer's prior authorization procedures and submit required documentation for approval.

Prior Authorization
Obtain PA for listed biologics and follow QL/SP handling
Some injectable biologic therapies list PA plus QL and specialty pharmacy (SP) handling; prescribers must obtain prior authorization and adhere to the QL where specified for biologic products.
PLEGRIDY peginterferon beta‑1a — Requirements/Limits = PA, QL (2 syringes/28 days), SP
REBIF interferon beta‑1a — Requirements/Limits = PA, QL (12 syringes/28 days), SP

Prior Authorization
PA required for listed biologics and targeted agents
Many biologic and targeted agents (including multiple adalimumab biosimilars) require prior authorization and often have quantity limits; providers must secure PA and comply with the QL for these agents.
Adalimumab biosimilars — Requirements/Limits = PA, QL (e.g., 2 pens/28 days), SP
SIMPONI golimumab — Requirements/Limits = PA, QL, SP

Prior Authorization
Obtain PA for migraine biologics and follow QL
Migraine monoclonal antibody products are listed with PA and specific quantity limits; prescribers must obtain prior authorization and follow the stated QL (e.g., AIMOVIG PA, QL 1 injection/28 days).
AIMOVIG (erenumab) — Requirements/Limits = PA, QL (1 injection/28 days)
EMGALITY (galcanezumab) — Requirements/Limits = PA, QL (1 injection/28 days)
AJOVY (fremanezumab) — Requirements/Limits = PA, QL (3 pens/84 days)

Step Therapy
Follow step therapy when 'ST' is indicated
Step therapy may apply when the formulary shows 'ST' in the Special Requirements column — providers should document prior trials of required agents per the plan before the requested drug will be covered.
Step Therapy is denoted by 'ST' next to products (e.g., aripiprazole oral solution = ST, FANAPT = ST)
If ST applies, clinicians must show prior use of required alternatives as part of authorization

Note
Check authorization flags (AC/PA) for antivirals — step specifics not listed
Some antiviral and other products include access/authorization flags (AC, PA) but the document does not define step sequences here; providers must follow the payer's authorization guidance when AC/PA/other flags are present.
APRETUDE and some antiviral entries include AC/PA annotations; verify payer-specific authorization rules

Note
If step therapy is not detailed, expect PA/QL controls
Where step therapy sequences are not specified in the formulary excerpt, providers should still expect PA and QL controls to be the primary utilization management tools and follow prior authorization rules accordingly.

Note

Documentation Required
Use the ID‑card number for exception requests; follow decision timeframes
Providers or members requesting an exception (coverage or copay waiver) must call the number on the member ID card; standard decisions are provided within 15 calendar days and expedited requests within 72 hours.
Call the number on the member ID card to request an exception
Standard decision timeframe: 15 calendar days; expedited: 72 hours

Documentation Required
Provide supporting clinical documentation with PA requests
The presence of 'PA' implies supporting clinical documentation must be submitted with the prior authorization request; although the formulary does not include templates, providers should attach relevant clinical rationale and records.
Include clinical justification and pertinent medical records with PA submissions
If QL is specified, document the clinical need for quantities above the limit when applicable

Documentation Required
Document quantity and dosing when PA involves QL
When quantity limits (QL) are specified, documentation supporting the requested dose/quantity may be required for PA; providers must ensure claims match the formulary QL or include justification for overrides.
Examples: many oral oncology and insulin products have explicit QLs (e.g., QL 120 tablets/30 days; insulin QL 100 mL/30 days)
Document dosing schedule and medical necessity when requesting amounts beyond QL

Billing Rule
Include authorization and QL details on claims for AC/PA products
Claims for products marked 'AC' or 'PA' must include authorization per payer procedures; quantity limits (QL) should appear on the claim and be supported by documentation when applicable.
Oral contraceptives with AC/QL (e.g., QL 28 tablets/21 days) require documentation of authorization on claim
Follow payer submission instructions to ensure PA/AC codes are billed correctly

Documentation Required
Ensure claims adhere to QL documentation
Adhere to the formulary's quantity‑limit documentation when submitting claims; QL values (e.g., syringe counts, mL volumes, tablet counts) must match the coverage limits unless PA is approved for exceptions.
Follow QL examples such as OVIDREL QL (2 syringes/30 days) and insulin QL (100 mLs/30 days)
If requesting quantities above the QL, submit PA with clinical justification

Documentation Required
PA + QL entries require documentation for both authorization and quantity
Product lines that show 'PA, QL' indicate the provider must submit a prior authorization request and support the requested quantity per the QL; examples include enalapril oral solution, QBRELIS, and FUROSCIX which list PA plus explicit QLs.
Enalapril (Epaned) oral solution — PA, QL (1200 mL/30 days)
QBRELIS lisinopril oral solution — PA, QL (2400 mL/30 days)
FUROSCIX furosemide kit — PA, QL (8 kits/180 days)

Documentation Required
Submit PA and route through specialty pharmacy when 'SP' is indicated
For drugs listed with 'PA' or 'SP', prescribers must submit prior authorization requests per payer processes and comply with any specialty pharmacy routing or quantity limits indicated on the formulary line.
Expect specialty pharmacy handling (SP) for many biologics and specialty agents
Follow PA submission instructions and include QL details as applicable

Denial Risk
Ensure PA/QL/SP requirements are met to avoid denials
Providers must submit prior authorization when indicated and adhere to stated quantity limits and specialty pharmacy routing for PA/QL/SP drugs; failure to obtain PA or to route through SP may result in denial.
Examples: TREMFYA, SKYRIZI, and other biologics show PA, QL, SP — follow PA and SP requirements
Claims without required PA/SP routing risk denial

Billing Rule
Prepare for PA and specialty pharmacy routing where 'PA' + 'SP' present
Expect PA and specialty pharmacy routing for items labeled 'PA' and 'SP' in the formulary; verify routing and authorization before dispensing high‑cost specialty products (e.g., VOWST).
VOWST — Requirements/Limits = PA, QL (12 capsules/12 months), SP
SKYRIZI and OMVOH list PA, QL and SP — confirm PA and specialty routing

Documentation Required
Verify product strength and requirement tags when requesting authorization
Use the formulary listing details (product name, strength, and requirement/limit tags such as QL, PA, ST, SP) to verify authorization and dispensing limits when submitting PA requests or claims.
Check exact product strength and the Special Requirements column before submitting authorization
Reference the QL value on the PA/claim submission to align with coverage rules

Documentation Required
Document QL on PA/claims for QL‑listed products
Quantity‑limit documentation is expected for products with a QL entry (for example, PLEGRIDY lists QL 2 syringes/28 days); providers should ensure claims and PA requests reflect the stated QL.
PLEGRIDY peginterferon beta‑1a — QL 2 syringes/28 days, PA, SP
Include QL on claims to align with formulary limits

Billing Rule
Route SP‑designated products through specialty pharmacy and obtain PA
Specialty‑designated products ('SP') require specialty pharmacy handling; providers should arrange dispensing through the specialty channel and obtain PA when indicated (examples: OTEZLA, TREMFYA).
OTEZLA — Requirements/Limits = PA, QL (60 tablets/30 days), SP
TREMFYA — Requirements/Limits = PA, QL, SP

Denial Risk
PA listing triggers requirement to obtain authorization
Prior authorization triggers on the formulary — drugs marked 'PA' require PA or coverage may be denied; providers must secure authorization before dispensing to avoid claim denial.
If prior authorization is not obtained for a PA‑listed drug, coverage may be denied

Denial Risk
Exceeding dispensing/quantity limits risks full cost to member
Dispensing quantities that exceed plan dispensing or quantity limits may result in the member being responsible for the full cost with no benefits applied; providers must adhere to QL/DL values or obtain PA for overrides.
Certain controlled substance rules may prohibit coverage beyond limits — patient may be liable for full cost

Prior Authorization
PA required for selected inhaled/complex aminoglycosides
PA is required for select inhaled/complex aminoglycoside products (e.g., KITABIS PAK, TOBI PODHALER, TOBRAMYCIN nebulized solutions); failure to obtain PA risks denial and specialty routing may apply.
KITABIS PAK — Requirements/Limits = PA, QL (56 containers/56 days), SP
TOBI PODHALER — Requirements/Limits = QL (224 capsules/56 days), SP PA

Prior Authorization
Obtain PA for specified antifungals (posaconazole, voriconazole)
Some antifungal agents and posaconazole formulations are marked 'PA' and will require prior authorization; providers must obtain PA to avoid claim denial for these antifungals.
NOXAFIL posaconazole (packets, suspension, tablets) — Requirements/Limits = PA

Prior Authorization
PA/SP required for select hepatitis C antivirals
Certain hepatitis C antivirals and high‑cost antivirals are designated PA and SP; providers must ensure PA and specialty pharmacy routing are in place before dispensing these agents.
EPCLUSA sofosbuvir‑velpatasvir — Requirements/Limits = QL (30 tablets/30 days), SP PA
HARVONI ledipasvir‑sofosbuvir — Requirements/Limits = PA, QL (30 packets/30 days), SP

Denial Risk
Claims may be denied if PA/SP/QL requirements are not satisfied
Drugs listed with Requirements/Limits = PA, SP, or QL may be denied if prior authorization, specialty pharmacy channel, or quantity‑limit requirements are not met; providers should verify and document compliance before dispensing.

Billing Rule
Document authorization and QL for contraceptives (AC/QL)
Contraceptives listed with AC or QL require documentation and adherence to the QL (e.g., many combined oral contraceptives show AC, QL 28 tablets/21 days); providers should include authorization on the claim when required.
Many contraceptives — Requirements/Limits = AC, QL (28 tablets/21 days); NUVARING — AC, QL (1 ring/21 days)

Prior Authorization
PA and QL apply to antidiabetic and insulin products
Antidiabetic agents and insulin products commonly have PA and/or QL notations (for example, MOUNJARO requires PA and QL; many insulins have QL 100 mL/30 days); providers must obtain PA where listed and adhere to QL.
MOUNJARO — Requirements/Limits = PA, QL (4 pens/180 days or 4 pens/28 days depending on strength)
Insulin products (FIASP, HUMALOG, etc.) — Requirements/Limits = QL (100 mLs/30 days)

Prior Authorization
Comply with PA and SP requirements for specialty drugs
Providers must meet PA or specialty pharmacy (SP) requirements for listed specialty drugs; failure to obtain PA/SP or to route through specialty channels may result in claim denial or non‑coverage.
CRENESSITY — Requirements/Limits = PA, QL, SP
Many biologics and specialty injectables require SP routing and PA

Prior Authorization
PA and QL for select oral solutions and kits
Coverage of select oral solutions and kits lists explicit PA and QL designations (e.g., enalapril oral solution, QBRELIS, FUROSCIX); providers must obtain PA and ensure claims reflect the QL to avoid denials.
Epaned enalapril oral solution — PA, QL (1200 mLs/30 days)
QBRELIS lisinopril oral solution — PA, QL (2400 mLs/30 days)
FUROSCIX furosemide kit — PA, QL (8 kits/180 days)

Prior Authorization
Follow PA/QL/SP controls for specialty/high‑tier drugs
Products designated 'PA/QL/SP' are subject to prior authorization, quantity limits, and specialty pharmacy controls; prescribers must submit PA, document quantity needs, and arrange specialty dispensing as required.
Examples include REPATHA, OTEZLA, TREMFYA, and numerous specialty injectables that carry PA, QL, and SP flags

Prior Authorization
PA + QL presence requires authorization and adherence to limits
Where a PA and QL are both present for a product (e.g., XELJANZ shown with PA and QL), providers must secure prior authorization and ensure the dispensed quantity does not exceed the QL unless supported by an approved PA.
XELJANZ 5 mg — Requirements/Limits = PA, QL (60 tablets/30 days)

Note

Quantity Limits and Dispensing Restrictions

controlled substances (general note)

Controlled substances — dispensing consequencesDispensing quantities exceeding plan dispensing/quantity limits may result in the member being responsible for the full cost with no benefits applied; state laws may prohibit coverage beyond limits for certain controlled substances.

Plan documentationDispensing limits and QL flags are noted next to medications in the drug list and should be checked on MyPrime.com or by calling the number on the ID card.

Azithromycin (various oral formulations)

Azithromycin formulations (suspensions and tablets)Azithromycin tabs/suspensions — QL 60 tablets per 180 days (Zithromax examples)

Z‑pak/tab strengthsApplies to azithromycin 250 mg and 500 mg tablet entries as listed

Clarithromycin ER 500 mg

Clarithromycin ER 24‑hour 500 mgRequirements/Limits = QL 28 tablets per 30 days

Other clarithromycin strengthsImmediate‑release strengths listed without QL unless specified

NUZYRA omadacycline 150 mg

NUZYRA (omadacycline) 150 mg tabletsRequirements/Limits = QL 30 tablets per 180 days

Formulation noteListed as NP with the stated quantity limit

Tobramycin nebulized/TOBI PODHALER

Tobramycin nebulized / TOBI PODHALERKITABIS/TOBI entries: PA and QL — QL 56 containers per 56 days (nebulized) or QL 224 capsules per 56 days for PODHALER; SP designation applies

Specialty routingProducts marked 'SP' require specialty pharmacy handling per listing

Itraconazole quantity limit

Itraconazole (Sporanox) capsulesRequirements/Limits = QL 120 capsules per 30 days

Oral solutionItraconazole oral solution QL 1200 mL per 30 days (separate entry)

Antiretroviral product QLs (e.g., BIKTARVY, GENVOYA, HARVONI)

Selected antiretroviral single‑tablet regimens (e.g., BIKTARVY, GENVOYA, COMPLERA, EPCLUSA)Requirements/Limits = QL 30 tablets per 30 days (product‑specific as shown)

Packets/pediatric formsSome formulations (pellet/pellet pack) also carry QL 30 tablets/30 days where noted

Oncology oral agent QL examples

Oral oncology examples (representative QLs)Examples include QL 120 tablets per 30 days; QL 240 capsules per 30 days; QL 30 tablets per 30 days depending on agent and pack

COMETRIQ (cabozantinib) kitQL 1 carton per 28 days for kit formulations

COMETRIQ (cabozantinib) QL

COMETRIQ (cabozantinib) kitRequirements/Limits = PA, QL 1 carton per 28 days, SP

Kit packaging noteKit entries list carton/pack QL rather than tablet count

Oral contraceptives QL examples

Combined oral contraceptives (representative)Requirements/Limits = AC, QL 28 tablets per 21 days (applies across many combined OCP entries)

NuvaRingRequirements/Limits = AC, QL 1 ring per 21 days

NUVARING QL

NUVARING (etonogestrel‑ethinyl estradiol ring)Requirements/Limits = AC, QL 1 ring per 21 days

Access class/authorizationNUVARING entries include AC and QL as shown in the drug list

Oral antidiabetics common QL

Oral antidiabetics (examples)Common QL = 30 tablets per 30 days (applies to FARXIGA, JANUVIA, JARDIANCE and many oral antidiabetic agents)

Higher QL examples for combination productsSome combination formulations list QL 60 tablets per 30 days (see SYNJARDY XR/TRIJARDY XR examples)

MOUNJARO QL/pens

MOUNJARO (tirzepatide) pensRequirements/Limits = PA, QL 4 pens per 28 days (some strengths) or 4 pens per 180 days (other strengths) — see line‑specific entry

Strength‑specific noteDifferent strengths have different QL periods (28 days vs 180 days) as listed

Insulin products common QL (100 mls/30 days)

Most insulin productsRequirements/Limits = QL 100 mL per 30 days (common dispensing limit for many insulin formulations and pen/cartridge entries)

Applies to rapid, short, intermediate, basal and premix insulinsSpecific product lines (HUMALOG, NOVOLOG, FIASP, LYUMJEV, HUMULIN, NOVOLIN, TRESIBA, TOUJEO, SEMGLEE) list QL 100 mL/30 days

Glucagon products QL notes

Glucagon emergency products (BAQSIMI, GVOKE, ZEGALOGUE)Quantity limits vary by product and are listed per line; no single uniform QL in these chunks

Claim/packaging noteCheck specific line entry for the exact QL and PA/AC flags

Multiple insulins QL examples

Multiple listed insulins (examples)Standard QL listed = 100 mL per 30 days for many insulin pen/cartridge and vial products

Products includedNOVOLIN N, NOVOLIN 70/30, NOVOLOG MIX 70/30, INSULIN GLARGINE‑YFGN, SEMGLEE, TOUJEO, TRESIBA — all show QL 100 mL/30 days

GALAFOLD QL

GALAFOLD (migalastat) capsulesRequirements/Limits = PA, QL 14 capsules per 28 days

Packaging noteListed with PA and SP designations where applicable

OVIDREL QL

OVIDREL (choriogonadotropin alfa) prefilled syringeRequirements/Limits = QL 2 syringes per 30 days

Fertility pack noteOVIDREL entry includes SP/PA where shown elsewhere in list

enalapril maleate oral solution QL

Enalapril maleate oral solution (Epaned)Requirements/Limits = PA, QL 1200 mL per 30 days

Line entryListed as requiring PA with explicit 1200 mL/30 days QL

QBRELIS lisinopril oral solution QL

QBRELIS (lisinopril oral solution)Requirements/Limits = PA, QL 2400 mL per 30 days

High‑volume liquid noteLarge‑volume oral solution QLs are listed in mL per 30 days as shown

FUROSCIX furosemide subcutaneous cartridge kit QL

FUROSCIX (furosemide subcutaneous cartridge kit)Requirements/Limits = PA, QL 8 kits per 180 days

Administration/benefit noteKit is specialty‑designated and requires PA; failure to meet PA/QL may result in denial

Examples across section

Representative examples across formularyExamples vary by drug (e.g., REPATHA 6 syringes/28 days; NEXLETOL QL 30 tablets/30 days; VASCEPA QL 240 caps/365 days or 120 caps/30 days; ENTRESTO sprinkle QL 240 capsules/30 days; NUCALA QL 3 mL/28 days or 1 syringe/28 days)

Interpretation guidanceFollow the per‑line Requirements/Limits shown in the drug list for exact QL periods and units

Site-of-Care and Specialty Pharmacy Routing

Note

Biosimilar Listings and Handling

Note

Definitions and Abbreviations

Initial Therapy Controls (High-Level)

PA/SP for specialty and certain high-cost drugs

Prior authorization (PA) or specialty pharmacy (SP) requirements — coverage requires ALL of the following when the product line indicates PA or SP:

PA required when indicated: If the product's Requirements/Limits include 'PA', a prior authorization must be obtained and approved prior to coverage; examples include listed inhaled aminoglycosides and certain antifungals/antivirals.

PA flags are shown next to specific agents

Specialty routing when indicated: If 'SP' is indicated, the product must be dispensed via the specialty pharmacy channel as specified by the plan to be covered.

SP designation present for many biologics and specialty agents

Documentation for PA/QL/SP: Providers must submit supporting clinical documentation with PA requests and comply with QL limits; failure to provide required information may result in denial.

Documentation expectations noted across product lines

Step therapy where indicated (initial therapy)

When step therapy applies (ST shown) coverage requires ALL of the following:

ST flag on product line: The Drug List shows 'ST' for the requested product or formulation, indicating step therapy applies for initial coverage.

ST notation appears adjacent to affected product lines

Required prior therapies: Prescriber must document that required prior, cost‑effective alternatives were tried and were ineffective or not tolerated before coverage of the requested drug is approved.

Specific alternative agents and failure definitions are defined in the plan step program (not fully included in the excerpt)

No ST listed: If 'ST' is not shown for a product, step therapy does not apply for that product in these excerpts and coverage is governed by PA/QL/SP as applicable.

PA/QL/SP remain primary utilization controls where ST absent

Step Therapy Flags and Tables

Drug / Drug Group	Special Requirements	Notes
Aripiprazole (oral solution, ODT, tablets)
ST; QL (900 mL/30 days for oral solution; QL 60 tablets/30 days for some tabs)
Step therapy indicated where 'ST' appears; per source aripiprazole oral solution and many aripiprazole tablet entries show 'ST' in Special Requirements.

Drug / Drug Group	Special Requirements	Notes
EPCLUSA (sofosbuvir-velpatasvir)
PA; SP; QL (30 tablets/30 days)
High-cost hepatitis C antiviral listed with PA and specialty pharmacy handling per formulary entry.

Observation	Special Requirements Present?	Source / Rationale
Presence of PA and QL flags across multiple sections but no step-by-step sequences provided
No (explicit sequences absent)
Document shows PA/QL flags for many drugs (e.g., oncology, antidiabetics) but does not define sequential step therapy algorithms in the cited chunks.

Drug	Special Requirements	Notes
MOUNJARO (tirzepatide)
PA; QL (4 pens/28 days or 4 pens/180 days depending on strength)
Listed with prior authorization and quantity limits; explicit multi-step requirements are not provided in these chunks.

Drug class / Examples	Special Requirements	Notes
GLP-1 agents (e.g., OZEMPIC, RYBELSUS, TRULICITY)
PA; QL as listed (examples: OZEMPIC PA, QL 1 pen/28 days or 3 mL/28 days)
GLP-1s in the listing show PA and QL flags; the document does not include detailed step therapy criteria for these agents in the cited chunks.

Drug	Special Requirements	Notes
KERENDIA (finerenone)
QL (30 tablets/30 days); ST
KERENDIA is specifically noted with 'ST' in Requirements/Limits indicating a step edit applies per the formulary excerpt.

Observation	Special Requirements Present?	Source / Rationale
Many product lines list Drug Tier with occasional PA/QL annotations but no ST sequences
No
Chunks show tier and occasional PA/QL annotations (e.g., digoxin entries) but do not present explicit step therapy rules in these excerpts.

Examples (selected high-cost agents)	Special Requirements	Notes
REPATHA (evolocumab - pens/cartridge)
PA; QL (6 syringes/28 days or 2 cartridges/30 days); SP
High-cost biologic with PA/QL and specialty designation suggesting utilization controls; explicit step sequences are not shown in these chunks.

Product / Formulation	Special Requirements	Notes
APRETUDE (cabotegravir - long-acting injection) and select bowel prep/access-class items
AC (access class) or similar designation shown for some formulations; PA/SP present for others
Access class (AC) designations are present for some formulations per brief/source; step therapy details for these entries are not provided in the cited chunks.

Drug / Formulation	Special Requirements	Notes
Aripiprazole (oral solution); Clozapine (ODT and suspension); FANAPT (iloperidone)
ST; QL as listed (e.g., aripiprazole oral solution QL 900 mL/30 days; FANAPT QL 60 tablets/30 days), other QLs for clozapine
Multiple antipsychotic/psychiatric oral formulations in the listing are marked 'ST' indicating step therapy applies where shown.

Drug	Special Requirements	Notes
FANAPT (iloperidone) and VERSACLOZ (clozapine suspension)
ST; QL (FANAPT QL 60 tablets/30 days; FANAPT titration packs QL as listed; VERSACLOZ QL 540 mL/30 days)
Entries explicitly show 'ST' for FANAPT and VERSACLOZ indicating step therapy applies; document does not provide the required prior agents or failure durations in these chunks.

Drug / Examples	Special Requirements	Notes
INGREZZA (valbenazine); XELJANZ (tofacitinib); selected biologics (e.g., evolocumab)
PA; QL; SP for many (e.g., Ingrezza PA, QL 28 caps/180 days, SP; XELJANZ PA, QL, SP)
Some agents are marked 'SP' (specialty) indicating specialty handling; many such entries also include PA and QL but explicit step-therapy sequences are not present in these chunks.

Observation	Special Requirements Present?	Source / Rationale
Overall: the document shows ST flags on selected products but does not define step-by-step algorithms in the provided excerpts
Mostly ST indicated on specific lines; PA/QL/SP are primary controls elsewhere
Source explains ST convention (chunk 10) and shows multiple product lines where 'ST' appears (psychiatric entries chunk 214-221, selected drugs like KERENDIA chunk 136) while many other sections rely on PA/QL/SP without step sequences.

Background

Specialty drugs are described as high‑cost or complex therapies that may be oral, topical, or injectable and are used to treat conditions such as hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis. Some specialty medications are provider‑administered and may be covered under the medical benefit rather than the pharmacy benefit; providers should verify benefit placement and site‑of‑care routing with the payer.

2025 Drug List (Pharmacy Benefit) — Formulary and Coverage Criteria

Sign up for all Blue Cross Blue Shield - Oklahoma policy alerts

Coverage Criteria and Formulary Listings

Coding and Quantity Limit Examples

Prior Authorization, Step Therapy, and Documentation

Quantity Limits and Dispensing Restrictions

Site-of-Care and Specialty Pharmacy Routing

Biosimilar Listings and Handling

Definitions and Abbreviations

Initial Therapy Controls (High-Level)

Step Therapy Flags and Tables

Background

Revision History